Transitions of Care and Disposition

Abstract

For every care transition (intra- or extra hospital), the practitioner will be able to formulate the following information:

• Physiological parameters with the individualised clinical interpretation

• Clinical narrative including communication needs and key informants

• Medication and any changes

• Thoughts about discharge planning and the home environment

• Escalation status including advance care plans

To assess and document suitability for discharge considering the ED diagnosis, including cognitive function, the ability in ambulatory patients to ambulate safely, availability of appropriate nutrition/social support and the availability of access to appropriate follow-up therapies, discharge planning should include an assessment of whether the patient is able to give an accurate history, participate in determining the plan of care and understand discharge instructions.

Provide skilled nursing homes and primary care providers with an ED visit summary and plan of care, including follow-up when appropriate.